Shame

Masaccio: The Expulsion of Adam and Eve from Eden 1425

Through the concrete physicality of the two figures and the arid landscape around them, Masaccio makes believable the first dolorous steps of human beings on earth, in the solitude of the shame of sin and the dramatic experience of pain. Quoted from ‘Medicine in Art’ Getty Publications. p.292

One of my patients, June, was standing near the entrance of the surgery when I came back from a home visit. June and I had been through a lot together in the two years since she came to see me with a breast lump, her subsequent mastectomy and chemotherapy, her husband’s dementia and death, and her depression and redundancy, but in recent months she had been steadily recovering and rebuilding her life and her health. The last few times we met she had been really well and we had time to talk about her plans for the future.

I was surprised then, when she turned abruptly away when I approached. I could tell something was wrong as I put my hand on her shoulder and I tried to look at her. There were tears rolling down her cheeks,

“Please go away, I don’t want you to see me like this. I’m so ashamed”

I was shocked, a sudden painful lump in my throat stopped me replying. What could be so awful, after everything we had been through, that she would feel like this? What had happened to our relationship to make her respond so strongly?

My immediate reaction was also to feel ashamed, ashamed that despite our frequent appointments I had no idea that she felt like this. I was ashamed that she was too ashamed to say.

I could smell the alcohol before she turned to face me, and I realised then how disheveled she was. “I’m so sorry”, she said. All I could think to say was, “me too”

Shame, according to psychologist Brené Brown, who has made the study of shame her life’s work, is not just is feeling bad about something you have done, shame is feeling bad about who or what you are,

Shame is easily understood as the fear of disconnection, is there something about me that if other people know it or see it, that I won’t be worthy of connection? … Shame is feeling that I am not worthy of love, care and attention … Underpinning shame is excruciating vulnerability, the fear of being seen as we really are.
Brené Brown: The power of vulnerability

Medical Sociologist Graham Scrambler who has a special interest in stigma and others, including psychologist Paul Gilbert who has spent years researching shame, make a distinction between ‘felt or internal shame’ and ‘enacted or external shame’. Felt (internal) shame refers to how we feel about ourselves. Enacted (external) shame is how we are viewed by others or how we think we are viewed by others. It is possible for someone who is obese to be aware that obesity is ‘highly externally shamed’, because we live in a society that frequently accuses obese people of being greedy and lazy, but not feel personally, internally shamed, because they are happy with their appearance, but there is a high correlation between external and internal shame … that is if one thought of oneself as inadequate one expected others to see the self in the same way.

We try to hide shame from others. Adam in the painting by Masaccio above is trying to conceal his identity and character, we are allowed to see his body but his face is burried in his hands. Eve by gendered contrast is attempting to hide her body but is really only able to cover her sexuality. Hers is by far the more disturbing image, unable to cover her face, her head is thrown back in despair. I find it fascinating, that six hundred years after this was painted, for men, shame is still strongly identified with character and for women, the experience is still so visceral. Because of shame, in social and clinical encounters we avoid scrutiny, by literally hiding away and avoiding social contact. When we do go out we are excessively submissive or passive and avoid questions or tell people what we think they want to hear rather than revealing what we are ashamed of. We deny our fears, uncertainty and vulnerability. In attempting to dull or suppress shameful feelings, we may abuse drugs or alcohol, or respond with irritability, anger or violence. Shame is strongly associated with depression, but even more strongly associated with social anxiety; we fear revealing our shame and withdraw from the world.

Given this, in my role as a general practitioner, shame must be almost ever-present, but I am writing about it now because I am ashamed that until recently, I’ve barely even noticed.

The things we are ashamed of.

“I haven’t made this appointment for myself, it’s about Dawn”. Dawn’s mother sat in front of me, looking serious, making sure I was paying close attention. Her 36 year old daughter was due to see me the following day. “She hasn’t seen a doctor in years. But she’s coming to see you about getting pregnant. But you need to know she’s really worried about her weight, that’s the reason she hasn’t been here before, she’s been trying to loose weight for years, and she knows that she has to lose weight, but she’s so sensitive about it, you know … so ashamed … in fact it’s got so bad she doesn’t even like going out these days, but when she comes to the doctors it seems like it’s the only thing you want to talk about and she never has a chance to talk about what she’s really worried about.”

It seems self-evident that for many women, the shame of being overweight is both felt and enacted, but the problem with things that seem self-evident is that being embedded in a shaming culture, we tend not to notice shame until we start to think about it. Sociologist Deborah Lupton has just published a book, called simply, ‘Fat’ which explores this in detail. Few doctors, I am sure, have ever questioned what we mean when we use the word ‘obesity’, other than a Body Mass Index of more than 30, but as Lupton explains,

‘obesity’ in particular as an officious medical term which designates fatness as pathology by its very use. Thus, to describe someone as ‘obese’ immediately places that person within the purview of medicine as someone who has the disease of ‘obesity’ and is therefore considered abnormal, inevitably unhealthy or at high risk of disease and thus as requiring medical intervention to reduce his or her weight.

GP Dr Ellie Cannon, recently wrote in the Daily Mail, “Fat, truth be told, is neither a feminist nor a  cosmetic issue. It is, quite simply, a health issue.” From my experience as a GP, ‘fat’ is anything but simple, as a previous blog about Doctors, patients and obesity makes clear. The pictures of scantily-clad young women published by the Mail that accompany Dr Cannon’s column online make it abundantly clear that fat is a very much a feminist and a cosmetic issue. Underpinning these different issues are the moral opprobrium and associated shame that accompany the experience of being fat and labelled obese.

We live in a medical culture that increasingly defines health and illness in terms of risk-factors, so that everyone is potentially ill. Associated with this is the idea that everyone is capable and hence responsible for modifying their risk factors. The neo-liberal emphasis on individual, rather than social change  reframes complex interacting risk-factors for disease as issues of personal behaviour and choice, putting the emphasis on self-care and personal responsibility rather than taking political action to tackle the social and economic determinants of health and desease. Piggybacking on this is IT entrepreneurialism and a burgeoning personal surveillance culture in which with the aid of mobile digital devices our habits may be continually monitored. All this is beautifully summarised by  Deborah Lupton.

The pressure on medical professionals to increase the emphasis on individual behaviour is evident in ‘Make Every Contact Count‘, a government attempt to get health professionals to discuss lifestyle habits whenever they meet a patient. Many GPs, aware of the myriad pressures on their patients, are uneasy about this and it has prompted one to respond with a blog titled, ‘The Right Not to be Lectured to’.

When an illness is viewed as resulting from carelessness, lack of self-discipline or licentious or illegal behaviour, the ill person becomes treated with moral opprobrium (see the essays in Brandt and Rozin 1997a; Lupton 1994, 1995, 2012). Obesity shares aspects of the moralizing discourses which give meaning to many medical conditions which are believed to be the result of ‘lifestyle choices’, such as lung conditions caused by smoking, liver conditions caused by excessive alcohol consumption, hepatitis spread through injecting drug use or sexually transmissible. (Lupton, ‘Fat’)

It is of little surprise then, that other habits like smoking and their associated diseases like cancer are also strongly associated with shame and stigma. The mainstream medical literature has surprisingly few papers on the subject of shame, but perhaps the best is about the stigma, shame and blame experienced by patients with associated with lung cancer.

Some patients said that family or friends had not been in touch since they heard about the diagnosis. One patient with mesothelioma said that his daughter had not telephoned because she felt “dirtied” by contact with cancer.

About 90% of lung cancer is associated with smoking, but it is not just the smoking that is the source of shame. Patients from around the world with different types of cancer report shame and stigma, as the two short films at the end of this blog show.

Other illnesses are even more strongly associated with shame, in particular mental illness and sexually transmitted diseases. Traumatic experiences, in particular child sexual abuse, rape and domestic violence are also strongly associated with feelings of shame. A considerable amount of my work as a GP involves caring for patients who attend very frequently, are addicted to drugs and alcohol, who repeatedly self-harm, who have eating disorders and who all share the experience of being sexually abused as children.  According to a national crime survey, 13% of respondents who experience rape or sexual assault express shame. They make a significant impact on me as a GP. People who are abused perhaps blame themselves in an attempt to rationalise their experience, or as a consequence of how they are forced to act or appear. In 86% of abused women, the self blame tendencies disappeared after they left the abusive relationship; once the external shaming abuse has resolved, for most women the internal shame is resolved.

When something awful happens, it is natural to ask, “Why is this happening to me, what have I done to deserve this?” And in desperately seeking an answer, we are led to conclude, “I must have done something, therefore this must be my fault”. Once the horror of the abuse is over, we are able to see from a distance, that actually we didn’t do anything to deserve it, and we are not to blame.

One lesson from The Book of Job is that when faced with extraordinary personal suffering, the ability not to blame oneself is exceptional. Job suffered extraordinary misfortune including the loss of all his family, his wealth and then, dramatically and horrifically, his health. Over and over again, he asked God what he had done to deserve to suffer. His friends, the priests insisted that he must have done something wrong, even if he couldn’t think what it might be. Most of us would have given in, and in despair, found some reason to blame ourselves.

Shame and ageing.

Ageing is associated with dependency and loss. Dependency on family, friends, professionals and the state. Losses include memory, mobility, continence, status and youthful looks.

The signs of ageing have become so abhorrent and pathological that they are conceptualized as distorting and hiding the ‘real’, essentially youthful self behind the ‘mask’, and as a disease needful of cure. D.A.Lupton

Elderly patients often endure embarrassing problems like incontinence for months or even indefinitely without asking for help. Falling is particularly associated with shame. Shame adds to the loneliness and isolation experienced by the elderly, exacerbated by loosing sight and hearing, mobility and confidence, friends and family. It is of little surprise, but very sad that shame is highest in older age.

Shame and deprivation

There is a great shame associated with poverty and life on benefits, exacerbated by a contemporary political culture that views people without jobs as a burden on respectable taxpayers. Poorer patients present later to doctors with symptoms of lung, bowel, breast and other cancers. In the last few months two of my patients, one with anal cancer and one with breast cancer, presented after suffering distressing symptoms for months. Both said they felt ashamed; they were afraid and embarrassed, they blamed themselves for the cancer and they blamed themselves for leaving it so long before coming to see me.

This quote below is typical of what my poorer patients say to me every week,

“Every time someone tells someone on sickness benefits that they are scrounging, or that they are not contributing to society, their self-confidence – already low from the humiliation of the benefits system and the misery of poverty as well as their experiences and suffering from their actual condition that got them there in the first place – slips further beyond the point of retrieval, until they are in danger of being frightened to attempt to partake in the world any more, yet alone go out and get a job.” Stigma of being on benefits prevents recovery from depression

In his book, ‘Chavs’, Owen Jones charts the demonisation of the working class. When I asked him why he didn’t write about the impact of shame and stigma he replied, “To be honest the problem was there’s no lack of possible material – which sort of makes the point in of itself” via twitter

In a 2011 BritainThinks survey about class:

There was a strong feeling in the focus groups that the noble tradition of a respectable and diligent working class was over. For the first time, I saw the “working class” tag used as a slur, equated with other class-based insults such as “chav”. I asked focus group members to make collages using newspaper and magazine clippings to show what the working class was. Many chose deeply unattractive images: flashy excess, cosmetic surgery gone wrong, tacky designer clothes, booze, drugs and overeating. By contrast, being middle class is about being, well, a bit classy. Independent

I work in an area with high levels of poverty, abuse, anxiety, depression, substance abuse, smoking and obesity. All these factors are ‘co-morbidities’, factors that compound one-another, amounting to more than the sum of their parts and so there is a great deal of shame. But it doesn’t matter where you live or work, because people suffer shame everywhere.

Professional shame

I think doctors and other medical professionals are particularly prone to shame. Those of us whose work is – as Iona Heath, president of the Royal College of GPs recently described it, ‘A Labour of Love’ – may be at particular risk. Our work has two characteristics:

First, work undertaken from fondness for the work itself and/or secondly, work that benefits persons whom one loves.

Both of these characteristics are relevant to the work of public service professionals.

My attachment to my work is so strong that it is undoubtedly part of my personal identity. This makes it very difficult to separate the emotions of attachment such as happiness or even love when things go well, and anger or sadness when they go badly.

Whereas guilt is feeling bad about what we have done, shame is feeling bad about what we are.

Medicine, especially the personal, holistic care that characterises general practice depends so much on matters of personality like kindness, respect, and empathy, that to fail clinically can be experienced as a failure of personality.

In dealing with others vulnerability, we tend to suppress or deny our own. In dealing with uncertainty, we tend to over-estimate diagnostic and treatment certainty. We are poor at admitting our mistakes and saying sorry. We are prone to drug and alcohol abuse and depression. All of these things are symptoms and signs of shame. We need not experience cancer or depression to treat patients with these problems, but, as Brown says, “shame is universal, everyone has experienced it, the only people who don’t experience shame have no capacity for human empathy or connection.”

Doctors also report feelings of shame in relation to our own experience of  sickness; ‘their professional identity is shattered and they fear colleagues’ disapproval’.

Shame nearly led to my death as a junior doctor, because I was ashamed at my inability to diagnose myself, and I feared humiliation more than death:

I had less than a month to go before the end of my second hospital job after qualification in 1996. I had been working as a surgical house officer for 5 months, and had taken off a weeks holiday to go walking in Scotland. I caught the train to Glasgow and the whole journey felt nauseous and feverish. When I arrived I met a friend and he could see I looked unwell. I joked that it was probably psychosomatic or Munchausen’s disease, because I imagined I might have appendicitis, one of the commonest conditions I dealt with as a junior surgeon. My stomach grumbled and I sweated uncomfortably for a few hours before catching the train on to Fort William. I prodded my stomach trying to elicit the clinical signs of appendicitis – rebound tenderness or guarding over McBurney’s point – without success.

At Fort William I figured that if I really had appendicitis I would be in far more pain, so I changed my working diagnosis to gastroenteritis and set off up the glen of Nevis. I made slow progress due to hopeless map-reading skills as much as deteriorating health, but eventually found a bothy before nightfall. Unfortunately a group of school children occupied it and I had to pitch my tent outside. I spent the night pouring with sweat and shivering with fevers, whilst insects feasted on my naked torso that hung outside the tent because the heat I was generating inside was unbearable. The following morning I felt worse than ever and I decided that I must have appendicitis. I asked the teacher supervising the group if I could use his phone -in those days a mobile phone weighed as much as a brick, had a battery-life of minutes, and cost a small fortune to use. He told me that he could only use it for emergencies for his group. I was in no state to argue, but in part I didn’t want to push it because of the nagging doubt that I might be wrong about my diagnosis. There was a rainbow in the sky before I left, and in the visitors book I wrote, that if I should die, then I’d like my friends and family to know that one of the last things I saw was a a beautiful rainbow.

It took me all day to walk back to Fort William even without getting lost. The last couple of miles into town were along a road. I was so tired and sick I really didn’t think I could make it, so I lay down in the road hoping someone would stop and pick me up. One car drove past, the driver swearing at me to get out of the fucking road, so I got up and staggered all the way to Fort William Hospital. I walked up to the main doors and stopped. I prodded my stomach again … and again. What if it wasn’t appendicitis? I could imagine the surgeon inside examining me sceptically, asking me where I trained and worked, and then asking me to list the signs and symptoms if appendicitis. I began to panic, I had come all this way, but I couldn’t go in to the hospital. Instead I turned around and headed into town to find a phone-box so that I could call a friend. I burst into tears as soon as Becky answered the phone and I blubbed my story. “What on earth are you waiting for? Go back to the hospital, of course it’s ok!” The relief was enormous, I went straight back and into the hospital. The surgeon couldn’t have been kinder, though when he told me that he thought I had a retro-peritoneal abscess and the last time they tried to treat one surgically they had ended up removing half the patient’s colon and this left them with a colostomy (or at least that’s how I remember it) I burst into tears again. Luckily for me, after 10 days of intravenous antibiotics and fluids I recovered without surgery.

Medical education has traditionally involved large amounts of shame and humiliation, with public interrogations of students on ward rounds in front of patients and peers. The fear of being unable to answer is so overwhelming that I was more afraid of mistaking something benign, like gastroenteritis for something potentially life threatening, with apparently classic signs and symptoms, like appendicitis, that I couldn’t present myself to hospital.

Professional shame and privilege.

I am extraordinary privileged. I am as secure as can be in a highly respected, well-paid profession, living and working in – and profiting from – an extremely unequal society. Simone De Beauvoir, reflecting on her shame of complicity in french Colonial domination, wrote:

I know that I am a profiteer, and that I am one primarily because of the education I received and the possibilities it opened up for me. I exploit no one directly; but the people who buy my books are all beneficiaries of an economy founded upon exploitation. I am an accomplice of the privileged classes and compromised by this connection … When one lives in an unjust world there is no use hoping by some means to purify oneself of that injustice; the only solution would be to change the whole world, and I don’t have the power. Quoted by Guenther

I know that I too am a profiteer. I cannot separate myself from the social and professional structures that protect me. I am associated not only with the good that is done in the name of my profession, but also with the careless, unethical, venal, self-serving, disrespectful, murderous behaviour that is carried out as well. I am ashamed that as my patients are being forced into deeper poverty and NHS services are under threat, I and other members of my profession not only failed to stop the appalling NHS bill, but many actively encouraged it and are profiting already from a system that rewards entrepreneurialism but not caring.

No profession is free of guilt and no man or woman is free of shame, except those who lack all capacity for human understanding. We cannot possibly care for others to our full potential without facing up to our own shame or admitting our own vulnerability.

Until we attend to the culture of shame that surrounds medical error, we will be only nipping at the edges of one of the greatest threats to our patients’ health. NYTimes

Shame and forgiveness.

In dealing with shame, we need to understand forgiveness, and to do this we need to be honest with ourselves. To be honest with ourselves we must acknowledge our weaknesses and to do this we must understand vulnerability. Whereas shame is characterised by fear of exposure, like Adam and Eve above,  vulnerability is openness. We almost all make the mistake of treating our own and others’ vulnerability as weakness, but to do so is to retreat into shame, self-loathing and hatred. But vulnerability need not be weakness; vulnerability can also be understood as the courage to expose one’s emotions including shame, to admit that we don’t know or to admit that we made mistakes.

I’ve written about vulnerability in another blog post inspired by psychiatrist, David Bell,

Our relationship with awareness of our own vulnerability is far from comfortable – we have a natural tendency to locate it in other people – it is he, not me, who is in need, it is she, not me, who is vulnerable. David Bell

The remarkable video lecture from The Forgiveness Project, linked below starts with a quote from Aleksandr Sozhenitsyn,

“If only it were all so simple! If only there were evil people somewhere insidiously committing evil deeds, and it were necessary only to separate them from the rest of us and destroy them. But the line dividing good and evil cuts through the heart of every human being. And who is willing to destroy a piece of his own heart?”
Aleksandr I. Solzhenitsyn, The Gulag Archipelago 1918-1956

Forgiveness requires not only coming to terms with our own dark-side, but also with our own vulnerability. The first presentation in the lecture is from a forensic psychiatrist who works at Broadmoor high security psychiatric hospital. In attempting to define violence she says it has to involve intentional suffering inflicted on the vulnerable and contempt for the victim’s vulnerability.

For the perpetrator, it is about denying their own vulnerability, and yet each one of us has been vulnerable and will be vulnerable. It is not possible to have a long and happy human life without being vulnerable. The exploitation and attack on vulnerability is about a type of fear and distress and panic … and I see it in society, we have a ‘denigration of vulnerability’ … [and this] fatally undermines our bonds of human connectivity.

We are only able to forgive if we are able to come to terms with our own vulnerability and the vulnerability of others. Brown links this to shame:

[we need] courage to be imperfect, compassion to be kind to ourselves, connection as a result of authenticity, fully embraced vulnerability, [and to] believe that what made [us] vulnerable was necessary, unrequited …

Therapy for homicide offenders at Broadmoor aims to help them ‘rework their narratives of passivity into narratives of agency, so they take responsibility for their actions. They are encouraged to accept who they are, so that they can move on’. From a Christian perspective much of this is basic scripture. To confess our sins is to acknowledge our imperfection, vulnerability and weaknesses and be honest with ourselves. To pray for forgiveness is to pray also that we are able to forgive ourselves. To believe in a loving God who loves us in spite of our sins, is to believe that we are worthy of love. Forgiveness is about not engaging with hatred, it is about finding the capacity to have compassion for the parts of ourselves we loath.

For serious offenders, and others who experience deep shame, group support is vitally important. Because we hide shame, we hide ourselves and the greater the shame, the greater the disconnection and social isolation. The process of forgiveness and recovery has to involve reconnecting with others. The antidote to shame is empathy.

Shame matters.

Shame is a cause of unhealthy behaviour, not the solution.

The way our patients present, with depression or addiction, anxiety or isolation may be a symptom or a cause of shame. It may be a sign of past or ongoing abuse. Shame stops patients at highest risk of serious illness from presenting with serious symptoms of heart disease or cancer, mental illness and other diseases. Shame stops doctors and patients from being honest with each-other; we collude and fail to address the important issues because we are afraid of opening ‘cans of worms’ and revealing shame. Shame makes us cling to false certainty, stops us admitting we don’t know and stops us saying sorry. Acknowledging our vulnerabilities – our fears and uncertainties – makes us more human. To address shame we need empathy and compassion. We need to created relationships that are safe, respectful and trusting enough that patients experiencing shame are able to be vulnerable, to open up emotionally and connect.

Doctors have a responsibility to act as our patients’ advocates, which must include speaking up about structural inequalities and social prejudice, the social determinants of shame.

Resilience and a solution to the problem of shame comes from believing that we are all worthy of love, care and attention. For Brown, “our job is to look at our kids & say, “you know what, you’re imperfect, and you’re wired for struggle, but you are worthy of love and belonging”.

For doctors, our job is to meet with our patients and say, “you know what, you’re imperfect, and you are struggling, but you are worthy of the very best care and compassion I have to offer”.

We all feel shame, you are not alone.

 

This is the fourth part of 4 related blogs

Part 1: Do Doctors need to be Kind?

Part 2:A Perfect Storm, welfare meets healthcare

Part 3: Medical Advocacy

Related posts:

Doctors, Patients and obesity

Who is the NHS for? Not me! Post about vulnerability denial and welfare cuts

Other references and articles:

When Doctors Make You Feel Guilty: Feeling ashamed of the bad behavior, instead of feeling ashamed of yourself, leads to better outcomes. The Atlantic 22/01/2014

Stigma, shame, and blame experienced by patients with lung cancer: qualitative study http://www.bmj.com/content/328/7454/1470

Something In the Air
When a Smoker Gets Lung Cancer, Sympathy Is Stained With Blame http://www.washingtonpost.com/wp-dyn/content/article/2008/12/12/AR2008121203425_pf.html

Shame and the Social Bond, A Sociological Theory. Thomas Scheff

Tracking the Trajectory of Shame, Guilt, and Pride Across the Life Span

Stigma and Silence: global perceptions of cancer

Stigma and Silence, Global perceptions of cancer 2

Brené Brown. The Power of  Vulnerability

Brene Brown: Listening to Shame

The Forgiveness Project lecture, “The Line Dividing Good and and Evil”

For professional resources and Paul Gilbert’s work see The Compassionate Mind Foundation and Hearts In Healthcare

http://www.compassionatemind.co.uk/resources/Compassion_Group_Therapy_Paper.pdf

Shame and the Temporality of Social life Lisa Gunther

Attachment styles, shame, guilt, and collaborative problem-solving orientations

The importance of physical contact in theraputic relationships Blog by Dr Laura Jane Smith ‘The Human Touch’

The Impact of Moral Stress Compared to Other Stressors on Employee Fatigue, Job Satisfaction, and Turnover: An Empirical Investigation http://rd.springer.com/article/10.1007/s10551-011-1197-y/fulltext.html
Penny Campling (author of Intelligent Kindness) How will shame play out in the wake of the Francis Report?

58 responses to “Shame

  1. Thank you. This is wonderfully written and deserves to be widely read. Thank you for sharing it here.

  2. Great blog Jonny. The best one yet, I reckon.

  3. This is an extraordinarily powerful piece of writing that moved me greatly. Thank you. I will return to it often and hope, as Anne-Marie says, that it is widely read.

  4. Thank you for such a well crafted, deeply researched and insightful piece.

  5. Quite simply the most powerful blog post I’ve read all year.

    If that’s what happens when a GP loves his job, well…there are insights in there that will save many people. Never mind any prescription. A bravura piece. Thanks for sharing it.

  6. Very well written piece, impressive. For those interested: a few years ago my colleagues and I published an article on sex education and embarrassment. Shame and embarrassment are not the same, but they are, of course, related emotions.

    Teijlingen van, E., Reid, J., Shucksmith, J. Harris, F., Philip, K., Imamura, M., Tucker, J., Penney, G. (2007) Embarrassment as a key emotion in young people talking about sexual health, Sociological Research Online, 12 (2) Online journal, web address: http://www.socresonline.org.uk/12/2/van_teijlingen.html

  7. Absolutely brilliant. I loved reading this. It really has made me consider this important dimension with my patients – something we all know about and are aware of, but something which gets lost in the busyness of day to day life. Thank you for raising awareness of that which is so important in care-giving, and yet rarely gets a mention.

  8. Wonderful compassionate blog thank you. I know all about shame, guilt and awful stigma with my clients, and once upon a time myself, I only wish more doctors would read your words, empathy is sadly lacking.

  9. As eloquent as ever, JT. Thoughtful, kind, humane. I have only one challenge to you which is about Christianity and the confessing of sins.

    Raised as a catholic, I was forced to confess my sins weekly – to entitle me to take ‘holy communion’ and reduce, ultimately, my time in Purgatory. To do this, I had to invent sins. As a consequence, I became a ‘sinner’ and lived with self-flagellating catholic guilt for years. There is no redemption in the confessional and the shame of my invented ‘sins’ has scarred me for life.

  10. What a thoughtful and compassionate post. You have managed to bring together lots of relevant academic literature with your own experiences and reflections in a remarkable piece. Medical educators, please encourage your med students to read this post. All doctors and other health professionals need to be aware of their powerful role in shaming patients, or conversely the role they can play in alleviating shame. I am writing at the moment on the use of disgust in public health campaigns, and believe that public health practitioners also need to be aware of how the messages they seek to promote using tactics to ‘shock the public out of their complacency’ may also work to humiliate and shame people.

  11. Jonny – one of the best essays I have read for a very, very long time. It is timely after the Compassionate Healthcare meeting on 12th November (www.humanvaluesinhealthcare.com has summary). Shame is, I’m told, one of the hardest issues to overcome; even more than guilt. I will repost this on my own blog pages, if only to never forget the ideas you have described to help me be a better person and doctor.

    By the way, Alys Cole-King has some excellent practical help at http://www.connectingwithpeople.org when everything may seem overwhelming.

  12. Reblogged this on Broken_Heart Blog and commented:
    A superb essay on addressing “Shame” in order to help people recover from depression and health care professionals develop better emotional resilience.

  13. Beautiful and moving. Your writing demonstrates how sharing the “deepest ,darkest moments” of people’s lives cannot be done without humanity, without commitment and without real presence in the contact.

  14. Just reading the last section (headed ‘Shame matters’) has helped me enormously in understanding the behaviour of loved ones. For a conscientious person in particular, the feeling that ‘You should be ashamed of yourself’ is destructive and seems to lead into a downward spiral of depression, with helplessness, sleeplessness, inability to function, and a grim resignation. I myself have felt this over my failure to keep order in my own household, and the only time I manage to restore some semblance of tidiness is when guests are expected. I worry about the message that this sends to my family: ‘I respect our guests more than you'; ‘You’re not worth the effort’, etc. However my own state of mind would not allow me to move forward until I suddenly became aware that there are many things more important than shame or embarassment, However, the wash of heat that scalds the cheeks or the excruciating desire to crawl away and hide are not meaningless/valueless. As well as a social standard that we expect others to live up to (and which one can choose to ignore), there is a touchstone or moral spirit-level which, if we have been lucky enough to be brought up in a caring and supportive environment with reasonable expectations of personal conduct, will monitor our reflections and drive us to resolve to ‘do better next time’. Normally called a ‘conscience’, this warning light should not be ignored. To act not in accordance with the standards of behaviour that you hold dear may be a recipe for emotional ill-health. So I would say that shame is useful; to ignore shame is harmful; but to try to instil shame or to use embarassment as a means of punishment and humiliation is not only futile but counterproductive and likely to induce anti-social behaviour.
    I will, as mentioned by Deborah Bowman, often return to read this. So much of what you have said rings true. Thanks for your guidance in bringing me to this understanding.

  15. Thank you for a wonderfully thought-provoking blog. I’m ashamed to say that in my GP career so far I have never thought once about shame as affecting my patients. It shines a new light on a great many encounters, from the well educated but independent and proud man who waited 6 months to see me with his clear history of bowel cancer, to the abuse victim who DNA’d her psychology appointment after waiting impatiently for it for 8 months, to the angry wife who thought she was being accused of feeding her husband too much potassium when he unexpectedly went into acute renal failure.

  16. wonderful writing, thank you

  17. Reblogged this on Kith and Kin : The Sisters Grinn and commented:
    Add your thoughts here… (optional)

  18. Such a wonderful and extensive treatment of shame from your unique vantage point. Congrats on FP!

  19. This is a wonderful, and important, post. Everyone should read it. Shaming figured largely in my childhood – to this day, even seeing the word makes me feel guilty and strange. This post has lessened that feeling.

  20. What an awesome blog. This had to be a hard one to write!

  21. Sadly, humanity has really lost its “shame” before a Holy and Totally Other “God the Almighty”! But when we know this “forgiveness”, then we enter into freedom. I am personally and wholly forgiven ‘In Christ’!

  22. Shame pervasively corrodes our cultural psyche and is central to many of our most insidious problems. Brene Brown is the hero of vulnerability, a strength not recognized–I’ve been a longtime fan. Kudos for cogently tackling a topic whose inherent nature is fraught with awkwardness. No one likes to reveal their shame and vulnerability and yet do it we must. For the resulting compassion is needed lest we destroy ourselves with our marauding egos.

  23. Thank you for this. I pinned it on my Emotional Fitness Training Board .http://pinterest.com/pin/147141112797075404/ I follow Jerome Kagan’s ideas on shame. He believes it is a necessary emotion to keep us from doing the unforgivable–cites Cain killing his brother. Notes that shame emerges as a human feeling when a child has the strength to kill a younger child. It needs to be strong and therefore gets carried forward with any behavior that might put us outside of the circle of caring. Think honor killings, think sin as thoughts and not deeds, think sexual shame.

    Kagans ideas play into my definition of mental ill health — Are you cruel or kind? Cruel to yourself, others? Kind to yourself and others? To me that is the basic question all need to ask about behavior and shame. Does it keep you from doing the unthinkable? Then it is useful, otherwise it needs banishing. The problem with things like addiction and fat lies in the muddy water of comforts that kill you slowly but comfort you greatly.

    Thank you for your blog.

  24. For sure, the points you raise are valid and I have experienced shame in some of these very areas. I have written about weight before, how we feel about our bodies, and society’s impact on that. I also have felt the shake of being broke and feeling that, although my daughter wants for nothing, I can not give her all I feel I should be able to provide. Shame (and it’s companion felling, “guilt,” can be very harmful and useless emotions. Suffering from OCD, I have been plagued by feelings of guilt most of my life. That said, I have to respectfully disagree with your assessment of how use of certain words, especially in a clinical setting, can be bad. Obesity for instance may cause shame, but when a doctor tells you (I use the term “you” in the general) that you are obese, whatever other “values” (lazy, unproductive, or whatever) you may attach to it, the truth is the truth. In MOST (not all, I’ll say) it IS because of poor diet or inadequate exercise. In MOST, being obese IS unhealthy. If a person is unhappy or shameful of the simple truth, as told by a medical professional, maybe they should do something about it. I am unhappy with my weight, especially post baby, but, by God, I’ve been exercising my ass off (excuse the pun) to try to become a healthier, happier me. AND at the same time, try to keep in mind not to be overly critical of myself, as it sets a poor example for my daughter. Anyway, thank you for your insightful post. This is just my two cents. I’m no doctor, but there it is. ;)

  25. Reblogged this on Journey of Peace and commented:
    Shame is perhaps the greatest barrier between us and God, second only to sin. Here is an insightful article on shame.

    • Of course theologically “shame”, i.e. guilt is the effect of sin in our lives! Even in postmodernity and a postmodern humanity feels this affect, though they have lost where this offense comes from. Very sad!

      • Very sad indeed. Something deep down inside the human soul refuses to believe that God can redeem us and make us good or acceptable…so we beat ourselves up when He is willing to give us grace. Very sad indeed!

  26. Very interesting article. A propos the painting, it is very interesting that ashamed Adam covers his face, whereas ashamed Eve covers her body. How should we interpret it? Doesn’t it seem that we can find here the old stereotypes about men as “owners” of the intellectual, and women as sexual creatures, representing the biological?

    • Of course Masaccio’s painting (1425) is Medieval, we should look to the spiritual and exegetical of the Genesis (1-3) account for the meaning of Adam & Eve. And even into the NT (2 Cor. 11:2, etc.) Note for example even the Neo-Orthodox position, and this is not really liberal.

      *Sorry, this subject does get “theological”! And I taught Theology in Israel in the late 90’s.

  27. wow~awesome article! I agree with your statement concerning the abused. I am a survivor of abuse. And some shame I actually owned. This Godly shame was met by grace and lead me to repentance. God took all my shame.

  28. it is one of the best writings of the latest days, welldone, and thank you.

  29. Definitely, beautiful use of imagery and this is a well crafted essay to capture something that is so personal yet everyone can relate to. Shame is like the other affective disorders, ‘anxiety, OCD, phobias etc,’ it is overwhelmingly crippling!

    However, I feel, ‘barrier,’ is not the right word to use to describe the shame felt by a woman experiencing domestic violence. Since, a barrier carries with it a chronic feeling, but the shame is very acute only occurring at the time of the abuse and not after, so I feel a ‘shield,’ is a more appropriate term to describe the protective nature of shame sadly, that a woman experiences during abuse.

    • Thanks Rafia, I struggled to find the right words to explain this and I think you make an important point, I’ll sleep on it and if I change it, you’re responsible!

      • Dear Rafia,
        After a few nights thinking, I’ve changed the wording about barriers and written about how self-blame becomes an explanation. Cecil Helman is a GP who has written about illness beliefs and the questions patients ask themselves, ‘why me, why now?’
        The Old Testament story of Job is a beautiful description of the anguish bought on by suffering without meaning. It is almost as if the lack of meaning is too much to bear, and so blaming ourselves is preferable to no explanation at all …

  30. This is incredible. Very powerful and very well-written. Thank you for sharing.

  31. I learned a lot reading this. Thank you very much for writing!

  32. This is a great post.
    I love Brene Brown and all her work on vulnerability and shame.

    I also think shame is one of the most destructive emotions – it distances us from others, it makes us scared, it makes us disgusted with ourselves. It makes us feel different and less than.

  33. I watched Brown’s TED Talk a while back, and gained so much valuable insight from it. So simple, yet extraordinary. Her work on vulnerability really opened my eyes to seeing how such a basic task can be terribly difficult for those more comfortable with shame. Glad you spread her message, and yours.

  34. There are so many issues in people’s lives that could be resolved with vulnerability and compassion shame is one of those big issues. The isolation that shame creates will lead to a death long before the heart stops beating. Thank you for writing this out so well.

  35. The topic addressed here is not one which I would willingly read – but I did, and I thank you for sharing it with us… The talks by Dr Brown were also wonderful…

  36. Reblogged this on bearspawprint and commented:
    “If only it were all so simple! If only there were evil people somewhere insidiously committing evil deeds, and it were necessary only to separate them from the rest of us and destroy them. But the line dividing good and evil cuts through the heart of every human being. And who is willing to destroy a piece of his own heart?”
    ― Aleksandr I. Solzhenitsyn, The Gulag Archipelago 1918-1956
    This quote was quoted within Shame.—–Well researched and documented. As I reaqched the end, I disovered this is Part 4 of a four part series.

  37. comeback to the bible, yesus is unswere to us

  38. Magnificent post. The best thing I’ve seen written on shame and its wide-ranging impact on human experience. Congrats on a very well-deserved FP!

  39. A lot to think about. Well said.

  40. Reblogged this on Kmareka.com and commented:
    Fascinating post on the nature and origins of shame.

  41. Reblogged this on logoclonia and commented:
    Add your thoughts here… (optional)

  42. One of the best posts I have read in a long time. Kudos!

    Congrats on FP!

  43. Such a complex topic, and such a thorough and well-constructed examination of it. We would all do well to delve into our own shame, for it surely exists somewhere within each of our psyches.

    And – congrats on being Freshly Pressed! This one deserved it. Thanks.

  44. wow… great post… :) keep it up

  45. When I see my GP, I feel shame. He is a wonderful, kind man, who treats me with respect and doesn’t nag me about my failings. Yet when I see him, I see all that I might have been, all that I was expected to be and all that I no longer am. When you see a doctor, you see his success, you see his power, you see his strength. His life could be a mess but you don’t know that. Thank you for raising this subject – I hope that many doctors read it.

  46. Dear Dr. Tomlinson,
    Sorry for not responding to your message on the 22nd, been busy with exams! Yes, I agree with the self-blame becoming an explanation this appropriately portrays the shame linked with domestic abuse. Having had a close encounter with domestic abuse on many levels I had to challenge your wording around it and your link with shame that you were drawing, sorry! Thanks for changing it, this suits the message that you were trying to get across better, I feel.

  47. Wow! This is a brilliant piece… Thanks for putting it up here! Cheers.

  48. Very good evaluation comig from a doctor. I’ve worked in a hospital as a psychologist and what you are saying about doctors’ attitudes is mostly true. Most of the time in the hospital I’d say “well, I know how you feel but feeling ashamed tells me how much you care about your health,etc. It means you are ready for the next step, etc.” Again, I feel you’d make great changes in where ever you work as a doctor. Very good indeed :)

  49. Elaine Tennant

    What a wonderful, insightful, compassionate piece. Thank you for giving me some food for thought while I nurse my baby in the wee small hours. I shall encourage my medical students to read your blog.

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